Results of a study showed a significant gap in access to tuberculosis (TB) diagnostic care among hospitalized patients with advanced HIV infection, both before and during the COVID-19 pandemic. These findings were published in the International Journal of Infectious Diseases.
This prospective study was conducted at 3 governmental hospitals in Ghana between October 2019 and July 2021. Researchers evaluated TB screening access among hospitalized patients (N=248) with advanced HIV infection. Screening access also was assessed among patients who were positive on the World Health Organization (WHO) 4-symptom screen (W4SS), and those with at least 1 WHO-defined danger sign. Data on patient characteristics and TB assessment were collected for the analysis, and clinical outcomes were evaluated at 8 weeks. Data were stratified by pre-pandemic and pandemic time periods. Cox proportional hazards regression was used to evaluate the effect of hospitalization during the COVID-19 pandemic on the risk for all-cause mortality at 8 weeks.
Among 248 patients included in the analysis, the median age was 41.5 (IQR, 34-48) years, 71.8% were women, 49.2% were diagnosed with HIV within the previous 3 months, 98.0% had WHO-defined clinical HIV stage 3 or 4 event at baseline, and 7.8% had previously received treatment for TB infection. Of 126 patients with HIV infection at baseline, 62.7% were receiving antiretroviral therapy.
Stratified by pandemic timing, patients enrolled during (n=106) vs prior (n=142) to the COVID-19 pandemic had higher CD4+ counts (median, 94.5 vs 62.5 cells/mm3; P =.029), lower rates of cough (59.4% vs 81.0%; P <.001), and lower rates of abnormal chest x-ray findings (62.5% vs 82.8%; P =.019).
Overall, 45.2% of patients were screened for TB via sputum assay and 42.7% were screened via chest x-ray. Among the subset of patients who requested TB screening via sputum assay (n=154) or chest x-ray (n=158), 72.7% and 67.1% received the requested evaluation, respectively.
The percentage of patients with confirmed, probable, or any TB infection was 6.1%, 12.6%, and 19.7%, respectively. Of 38 patients who were referred for TB treatment, treatment was initiated in 86.8%.
The overall mortality rate at 8 weeks was 25.2% (95% CI, 20.0%-31.1%), with mortality occurring at a median of 17.5 (IQR (10-33) days following hospital admission.
Stratified by period, no significant effects were observed between the pandemic and rates of TB testing, prevalence, treatment, or outcomes.
Patients with self-reported cough (adjusted risk ratio [aRR], 2.37; 95% CI, 1.80-3.13; P <.001) and CD4+ counts equal to or above 100 cells/mm3 (aRR, 1.31; 95% CI, 1.22-1.41; P <.001) were more likely to be tested for TB infection, whereas those who were unable to walk unaided were less likely to be tested (aRR, 0.78; 95% CI, 0.65-0.94; P =.010).
The occurrence of mortality at 8 weeks was associated with male sex (adjusted hazard ratio [aHR], 1.93; 95% CI, 1.17-3.18; P =.010) and low CD4+ count (aHR, 1.81; 95% CI, 1.02-3.20; P =.041).
These findings may be biased as data collection was potentially interrupted during the COVID-19 pandemic.
According to the researchers, “Missed or delayed TB diagnosis may be critical in this population with 25% of patients dying with 8 weeks from hospital admission.”
Åhsberg J, Bjerrum S, Ganu VJ, et al. The in-hospital tuberculosis diagnostic cascade and early clinical outcomes among people living with HIV before and during the COVID-19 pandemic – a prospective multisite cohort study from Ghana. Int J Infect Dis. 2023;128:290-300. doi:10.1016/j.ijid.2022.12.044